Infectious endocarditis. It is a serious disease, with a varied clinical presentation, which is often confused with other heart conditions and other apparatus and systems; hence its great medical importance, because if it is not recognized and treated properly, it can be fatal.
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- 1 Definition
- 2 Classification
- 3 Clinical manifestations and Diagnosis
- 4 Duke criteria modified
- 5 Heart disease at risk of infective endocarditis
- 6 Procedures requiring prophylaxis
- 7 Indications for surgical treatment
- 8 Complications
- 9 Indicators of poor prognosis
- 10 Sources
- 11 External links
Anatomoclinical entity characterized by microbial infection of the parietal valvular endothelium or both caused by different species of microorganisms whose colonies are deposited below the fibrin surface.
- It manifests with marked toxicity.
- Withering course
- Rapid destruction of endocavitary structures.
- It generally affects healthy hearts.
- It causes septic metastases.
- Causal Germ: Streptococcus viridans.
- If not treated, it is fatal in a few days or weeks.
- General nonspecific manifestations of low toxicity.
- It occurs insidiously.
- It is located in previously damaged hearts.
- It does not usually produce septic metastases.
- Causal Germ: Staphylococo aureus.
- Even without treatment the patient can live up to a year.
- Infective native valve endocarditis (EIVN)
II.Infectious prosthetic valve endocarditis (EIVP)
III.Infectious endocarditis in parenteral drug addicts (EIADVP)
Both classifications can be merged example:
- Native mitral valve streptococcal subacute infectious endocarditis.
- Staphylococcal acute infectious endocarditis of the prosthetic aortic valve.
Clinical manifestations and Diagnosis
IE should be suspected in the following cases:
- New regurgitant heart murmur.
- Embolic events of unknown origin.
- Sepsis of unknown origin (especially if associated with an organism causing IE)
IE should be suspected if fever is associated with:
- Intracardiac prosthetic material.
- EI Background.
- Valvular disease or previous congenital heart disease .
- Other predispositions to IE (eg, immunodeficient status).
- Predisposition and recent intervention with associated bacteremia.
- Evidence of congestive heart failure.
- New driving disorder.
- Positive blood culture with a typical organism causing IE or positive serology for chronic Q fever (microbiological results may precede cardiac manifestations).
- Vascular or immune phenomenon: embolic event, Roth spots, splinter hemorrhages, Janeway lesions, Osler’s nodules.
- Focal or non-specific neurological symptoms and signs.
- Evidence of pulmonary embolism / infiltration (right IE).
- Peripheral abscesses (renal, splenic , cerebral, vertebral) of unknown cause.
Modified Duke criteria
Duke’s criteria modified for the diagnosis of infective endocarditis.
Positive blood cultures for IE:
- Typical microorganisms that match the IE of two independent blood cultures:
Streptococcus viridans, S. bovis, HACEK group, Staphylococcus aureus, or community-acquired Enterococci in the absence of a primary focus
- Microorganisms that match IE with persistently positive blood cultures:
At least two possible positive cultures of blood samples taken at 12 h intervals or Three or most of more than four independent blood cultures (with the first and last samples taken at intervals of at least 1 h)
- Single positive blood culture for Coxiella burnetii or phase I IgG antibody 1: 800
Evidence of endocardial involvement
- Positive echocardiography for IE.
- Vegetation; abscess; new partial dehiscence of prosthetic valve.
- New valve regurgitation.
- Predisposition: predisposing heart disease, use of drugs by injection.
- Fever: temperature> 38 ° C.
- Vascular phenomenon: severe arterial embolus, septic pulmonary infarction, aneurysm, intracranial hemorrhages, conjunctival hemorrhages, Janeway lesions.
- Immune phenomenon: glomerulonephritis, Osler’s nodules, Roth’s spots, rheumatoid factor.
- Microbiological evidence: positive blood culture that does not meet an important criterion or serological evidence of active infection.
- with an organism that fits the IE.
The diagnosis of is definitive in the presence of:
- 2 major criteria, and / or
- 1 major criterion and 3 minor importance, and / or
- 5 minor criteria.
The diagnosis of IE is possible in the presence of:
- 1 major criterion and 1 minor importance, and / or
- 3 minor criteria.
Heart disease at risk of infective endocarditis
There are heart diseases at risk of IE for which prophylaxis is recommended when performing a high-risk procedure:
- Valve prostheses (including bioprostheses and homografts).
- Previous infectious endocarditis.
- Cyanotic congenital heart disease.
- Patent ductus arteriosus.
- Aortic insufficiency .
- Aortic stenosis .
- Mitral regurgitation .
- Double mitral injury.
- Ventricular septal defect.
- Aortic coarctation .
- Intracardiac lesions operated with residual hemodynamic abnormalities or prostheses.
- Pulmonary systemic short circuits with surgical correction.
- Pure mitral stenosis.
- Tricuspid valve disease.
- Pulmonary stenosis.
- Hypertrophic cardiomyopathy.
- Mitral prolapse with valve insufficiency and / or redundant leaflets.
- Bicuspid aorta with slight hemodynamic abnormalities.
- Aortic sclerosis with slight hemodynamic abnormalities.
- Calcific degenerative valvular lesions in the elderly.
- Intracardiac lesions operated without hemodynamic abnormalities in the first 6 months after the intervention.
- Ventricular septal defect (CIA) ostium secundum.
- CIA and ductus repair after 6 months and without residual injuries.
- Coronary surgery.
- Mitral prolapse without valve failure.
- Functional puffs.
- Kawasaki disease without valve dysfunction.
- Previous rheumatic fever without valve dysfunction.
- Pacemakers (endocavitary and epicardial) and implanted defibrillators.
- Mild Doppler valve insufficiency without structural abnormality.
- Atherosclerotic plates.
Procedures requiring prophylaxis
The procedures for which prophylaxis is recommended in risk patients are:
- Dental interventions that cause gingival or mucosal bleeding including dental cleaning and tartar removal.
- Tonsillectomy and adenoidectomy .
- Surgery of the gastrointestinal muscle or the upper part of the respiratory system.
- Bronchoscopy with a rigid bronchoscope.
- Sclerotherapy for esophageal varices.
- Esophageal dilation.
- Retrograde endoscopic cholangiography with biliary obstruction.
- Gallbladder surgery.
- Cystoscopy, urethral dilation.
- Urethral catheterization if there is a urinary infection.
- Surgery of the urinary system including the prostate.
- Incision and drainage of the affected tissue.
Indications for surgical treatment
The main indications for surgery in patients with infective endocarditis are:
- Moderate to severe congestive heart failure.
- Unstable prosthesis.
- Persistent and uncontrollable infection despite correct antimicrobial treatment.
- Confirmation of abscesses, pseudoaneurysms, abnormal communications, such as fistulas or rupture of one or more valves; conduction disorders, myocarditis, or other findings indicating local spread (locally uncontrolled infection).
- Recurrence of prosthetic valve endocarditis after correct treatment.
- Repeat embolisms with persistent images of large, mobile vegetation.
- Involvement of microorganisms that do not respond normally to antimicrobial therapy.
- Congestive heart failure.
- Thromboembolism at different levels.
- Acute kidney failure.
- Severe valve damage.
- Brain abscess.
- Rheumatic complications.
- Myocarditis and / or pericarditis.
Poor prognosis indicators
- Advanced age.
- Infectious endocarditis on prosthetic valve.
- Insulin-dependent diabetes mellitus.
- Comorbidity (cardiovascular, kidney disease
or previous lung).
- Presence of complications of infectious endocarditis.
- Heart failure.
- Kidney failure .
- Septic shock.
- Perianular complications.
- Staphylococcus aureus.
- Gram-negative rods.
- Perianular complications.
- Regurgitation of the severe left valve.
- Lower left ventricular ejection fraction.
- Pulmonary hypertension.
- Large vegetation.
- Severe prosthetic dysfunction.
- Premature closure of the mitral valve and other signs of elevated diastolic pressure.